The recent explosion of a gas pipeline in Putra Heights has provoked a wave of technical scrutiny across the industry. However, amid discussions focused on system design, excavation standards, and safety protocols, one vital dimension remains underexplored—human factors. This newsletter aims to illuminate how human-system interactions, organizational culture, and leadership played a critical role in this tragic event.

Understanding Human Factors in Industrial Incidents

Defining the Discipline: Human factors is a multidisciplinary field that studies how humans interact with systems, environments, and technologies. In the gas and energy sectors, this includes mental workload, fatigue, communication, training adequacy, and organizational norms.

Key Insight: When systems are developed without accommodating human capabilities and limitations, the probability of failure rises dramatically.

Human Error: More Than Meets the Eye

Types of Human Errors: Drawing from Reason’s (1990) taxonomy, human errors fall into three broad categories:

• Slips and lapses – Unintentional mistakes, often due to fatigue or distractions (e.g., failure to notice a leak).
• Mistakes – Errors from incorrect understanding or poor training (e.g., misinterpreting pipeline location data).
• Violations – Deliberate rule-breaking, potentially encouraged by a culture that overlooks risks.

Example: Excavation conducted without reviewing utility maps may not stem from negligence alone but from broader training or procedural gaps.

“Until we treat human factors as foundational—not optional—we are destined to repeat these tragedies.”

Latent Failures: The Hidden Triggers

Organizational Weaknesses Behind Frontline Errors: Latent failures are systemic flaws that set the stage for active errors. These include: